New 50-State Survey Finds Few States Have Taken Action to Cut Medicaid To Date, But Many See Potential For Revisions If Budget Constraints Worsen

WASHINGTON – With states confronting a weakening economy, enrollment in Medicaid began to rise last year with states expecting even larger increases for fiscal year 2009, according to a new 50-state survey released today by the Kaiser Family Foundation’s Kaiser Commission on Medicaid and the Uninsured (KCMU). With the increased enrollment, Medicaid spending is also rising more rapidly than in the recent past, raising the potential for program cutbacks as states confront the combined impact of more enrollees and fewer available resources.

The survey finds that Medicaid enrollment across the country grew 2.1 percent in fiscal year 2008, more than erasing a slight decline in enrollment experienced the previous year. States also experienced spending growth of 5.3 percent, up significantly from the previous two years. For fiscal year 2009, states expect to see even larger increases in Medicaid enrollment (3.5 percent) and spending (5.8 percent).

The survey comes as states face serious financial constraints, with 30 states having confronted significant budget shortfalls as they prepared their fiscal year 2009 budgets. Looking ahead, two thirds of state Medicaid directors say that there is at least a 50-50 chance that they will face a shortfall in their Medicaid budgets during the current year. Such shortfalls could force mid-year changes to control costs, potentially including cuts in eligibility and outreach efforts.

“We’re just beginning to see the impact of the economic slowdown, as growing Medicaid enrollment and shrinking revenues pose new threats for health coverage,” said Diane Rowland, executive vice president of the Kaiser Family Foundation and Executive Director of KCMU.

Medicaid directors attributed the growth in enrollment and spending to the weakened economic outlook facing their states. During economic downturn, as unemployment rises people may lose employer-based coverage and incomes decline, making them potentially eligible for a state’s Medicaid program. Ongoing state efforts to address the uninsured such as expanding Medicaid eligibility, improving outreach and simplifying enrollment procedures also played a role in the growth.

Medicaid Policy Initiatives for Fiscal Years 2008 and 2009

Conducted by Kaiser researchers with the KCMU and researchers with Health Management Associates, the eighth annual budget survey of state officials found that more states made restorations, enhancements or expansions to their Medicaid programs than made cuts for fiscal years 2008 and 2009. These include changes to provider reimbursement levels, in Medicaid eligibility requirements and enrollment processes, in benefits, and in home- and community-based services for long-term care.

The changes reflect efforts that began during the favorable economic climate in 2007, as states prepared their fiscal year 2008 budgets, and continued for fiscal year 2009, though this year’s expansions were fewer and smaller in scope. This pattern is similar to what occurred at the start of the last economic downturn from 2001 to 2004, when states did not immediately implement widespread actions to cut Medicaid but made significant cuts later.

Other key findings from the survey include:

Documentation requirements. Most states reported continuing problems related to the implementation of new documentation requirements for Medicaid enrollees and applicants to demonstrate their citizenship and identity, as required by the Deficit Reduction Act of 2005 (DRA). Overall, 30 states reported that the requirements significantly increased the time needed to determine eligibility; 24 states reported increased backlogs of applications; and 22 states reported an increase in the number of application denials.

DRA authority on benefits, cost-sharing. A small number of states continue to make use of new approaches to alter Medicaid benefits, impose new cost-sharing requirements and permit certain providers to deny services to enrollees who fail to pay their co-payments, as authorized by the DRA. By 2008, eight states used this authority to modify benefits, four states used it to allow providers to deny services to some who did not make co-payments, and one state (Wisconsin) used it to impose nominal copayments to some enrollees in managed care.

Use of managed care. In Fiscal Year 2008, nearly one third of states expanded their managed care programs. The most significant trends involved including people with disabilities in managed care, expanding managed care service areas and requiring enrollment into managed care when it had previously been voluntary. States continue to focus on quality efforts such as pay-for-performance and implementation of new information technology initiatives.

Uncertainty about children’s coverage. A number of states reported that they limited their expansion of coverage of children due to the new federal State Children’s Health Insurance Program requirements or the uncertainty of ongoing funding, given Congress has only reauthorized the program through March 2009. Budget constraints resulting from the weakened economy add to this uncertainty.

Looking ahead. When asked about the most significant issues facing the Medicaid program, Medicaid directors cited financing issues and the economy, the current status of the federal-state partnership around Medicaid, and the challenge of implementing new initiatives ranging from new information technology systems, quality initiatives or efforts to cover more of the uninsured. With a new Administration and Congress, the prospect of a broader discussion around national health reform and the trajectory of the economy also are expected to have implications for the Medicaid program over the next year or two.

Today’s report, Headed for a Crunch: An Update on Medicaid Spending, Coverage and Policy Heading into an Economic Downturn – Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2008 and 2009, is available online at http://www.kff.org/medicaid/7815.cfm. In addition, an audio press briefing on the release will be available after 6 p.m. ET today.

HHS Announces $36 Million to Help Older Americans and Veterans Remain Independent

Grants include first-time collaboration with VA to support America's veterans

The U.S. Department of Health and Human Services (HHS) today announced $36 million in new grant programs to 28 states to help older Americans and veterans remain independent and to support people with Alzheimer's disease to remain in their homes and communities. Just over $19 million of this funding involves a new collaboration with the U.S. Department of Veterans Affairs (VA).

HHS Secretary Mike Leavitt and VA Secretary James Peake, M.D., announced the joint effort to provide essential consumer-directed home and community-based services to older Americans and veterans of all ages, as part of a Nursing Home Diversion (NHD) grants program. The new initiative builds on the similar missions of HHS and the VA with regard to caring for the populations they serve. In addition, Secretary Leavitt announced a $17 million investment to improve the delivery of home and community-based services to people with Alzheimer's disease and their family caregivers.

In announcing the collaboration, Secretary Leavitt said, "This historic HHS-VA initiative combines the expertise of the HHS' national network of aging services providers with the resources of the Veterans Health Administration to provide more people, including our nation's veterans, with improved long-term care options. This unique effort supports the President's New Freedom Initiative which calls upon all federal agencies to help people who need long-term care and prefer to live in their own homes and communities to do so. Through this joint program, many people who would have previously been placed in nursing homes will be able to remain at home."

"Our mission is to honor and support America's veterans, and this collaboration provides an additional opportunity to do that by offering more services, choices and control over decisions to veterans in the least restrictive environment consistent with their needs and preferences," Secretary Peake said.

The new program will be administered by HHS' Administration on Aging (AoA) in collaboration with the Veterans Health Administration. Under the program, $10.5 million is being provided by HHS through AoA, and $5.7 million by the states. VA estimates purchasing at least $3 million in veteran-directed home and community-based services for older veterans and for recently returned veterans with long-term care needs. The number of veterans over age 85 has tripled during the past decade, creating a significant expansion in the need for long term care.

"The HHS funding is specifically designed to reach people who are not eligible for Medicaid, but who are at high risk of nursing home placement and spend-down to Medicaid -which often occurs when private pay individuals enter a nursing home," said Assistant Secretary for Aging Josefina G. Carbonell. "The program will also offer consumers more control over their long-term care, including the ability to determine the types of services they receive and the manner in which they receive them, including the option of hiring their own care workers."

The $17 million for individuals with Alzheimer's disease and their caregivers involves grants to 22 states under AoA's Alzheimer's disease demonstration programs. States were able to apply for two types ofgrants: Innovation Grants and Evidence-Based Program Grants. Innovation Grants will demonstrate new approaches to delivering services and supports, and the Evidence-Based Grants will support the replication of science-based interventions that have already proven to be effective at helping people with Alzheimer's Disease and Related Disorders to continue to live in the community.

National Federation of the Blind and Commonwealth of MassachusettsAnnounce Agreement with Apple to Make iTunes Fully Accessible

Baltimore, Maryland (September 26, 2008): The National Federation of the Blind and Massachusetts Attorney General Martha Coakley today announced a cooperative agreement with Apple, Inc. to make Apple’s iTunes software, iTunes Store, and iTunes U more accessible to the blind. On September 9, Apple released iTunes 8, which contains significant accessibility improvements. Under today’s agreement, Apple will make iTunes U (a dedicated area of the iTunes Store for content provided by colleges and universities) fully accessible by December 31, 2008, and will ensure the full accessibility of the iTunes software and the rest of the iTunes Store to blind people using both Mac and Windows operating systems by June 30, 2009. Over the next three years, Apple will continue to work with officials in the office of the Massachusetts Attorney General and the National Federation of the Blind to ensure that the iTunes services remain accessible to the blind and that accessibility issues are resolved. Apple has also agreed to contribute $250,000 to the Massachusetts Commission for the Blind to assist the agency in providing adaptive technology to blind residents of the Commonwealth of Massachusetts.

Dr. Marc Maurer, President of the National Federation of the Blind, said: “Computer technology is a critical means of access to business, education, information, and entertainment in the twenty-first century, and the blind must have equal access if we are to be equal participants in society. By making its extremely popular iTunes service fully accessible to the blind, Apple is setting an example that should be followed by the entire information technology industry. The National Federation of the Blind is pleased to have worked with Attorney General Coakley and her staff to reach this important agreement with Apple, and we will continue to work tirelessly until the blind have equal access to the full range of products and services available to the public through the Internet and other information technologies.”

“Our office is committed to providing equal opportunity to all citizens of the Commonwealth of Massachusetts,” said Attorney General Martha Coakley. “This agreement will benefit blind Commonwealth citizens and all blind Americans by making one of the most widely used computer applications accessible to them. I applaud Apple for its commitment to accessibility and look forward to continuing to work with the National Federation of the Blind to ensure that rapid progress is made in making the iTunes software and services usable by everyone.”

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About the National Federation of the Blind

With more than 50,000 members, the National Federation of the Blind is the largest and most influential membership organization of blind people in the United States. The NFB improves blind people’s lives through advocacy, education, research, technology, and programs encouraging independence and self-confidence. It is the leading force in the blindness field today and the voice of the nation's blind. In January 2004 the NFB opened the National Federation of the Blind Jernigan Institute, the first research and training center in the United States for the blind led by the blind.

From Montana ADAPT (9/27):Missoula, MT--- In a packed room, with U.S. Senate Finance Committee staff
linked in by phone, Montana People First members and others offered personal
testimony about the pain and suffering caused by the SSI "marriage penalty."
Following the testimony, they presented over 2500 petition signatures they had
collected from citizens all over Montana to a local staff member of Sen. Max
Baucus, who chairs the Senate Finance Committee. In addition to the monetary
penalty suffered by SSI recipients who marry, those presenting testimony cited
additional penalties such as:

Not being able to openly celebrate their love
and commitment to one another in the company of friends and family

Not
being able to inherit one another's estates as a spouse

Not being able to
get information when their partner is in the hospital

Not being able to
make end of life decisions for their partner when necessary

Not being able
to make funeral arrangements for their partner

Not being able to live
openly as husband and wife

Montana People First members hope that their
efforts will inspire others around the country to join them in asking their
Senators and Representatives to take legal action to remove the marriage penalty
from the SSI program. More information is available below in the Media Advisory
issued on Thursday by Disability Rights Montana, which is supporting the Montana
People First Senate in the campaign to end the SSI marriage penalty.

What:
Present personal testimony on the SSI “Marriage Penalty,” and a petition with
2500 signatures to Montana's Congressional delegation. The testimony and petition ask for Congress to change SSI policies that discriminate against people with disabilities who marry, and that punish them for celebrating marriage and family values.

Why:
Many people with disabilities live on a $637/month federal SSI benefit, an
amount that is about 75% of the poverty level. When two unmarried SSI recipients live in the same household and share
expenses, each continues to receive a full $637/month SSI benefit. However, when
two people with disabilities of the opposite sex marry, and one or both receive
SSI, their combined benefit as a couple ($956/month) is reduced to 75% of the
total of their two individual benefits($637/mo + $637/mo =
$1274/month)

As
a result, SSI recipients with disabilities who wish to marry like their typical
peers, in accordance with social convention and/or their faith, hesitate to do
so, or choose not to marry at all
rather than risk the loss of precious dollars needed for basic food and shelter,
as well as for disability related expenses.

Seeking
to challenge this policy that treats people who share households differently
based on their marital status, People First of Montana enlisted the assistance
of several other groups to form a Montana Marriage Penalty Task Force. Members
of the Task Force come from Disability Rights Montana, Montana People First, the
Montana Advocacy Coalition, the State Independent Living Council, the disability
rights organization ADAPT, the Rural Institute at the University of Montana and the general citizenry.

Why
is there a marriage penalty?

The
original reduction in benefits for a married couple, or a couple deemed to be
married under Social Security rules, was put into place on the premise that
there are “economies of scale” when two or more people live together. This
“economies of scale” premise in SSI was patterned on the “economies of scale”
present in the TANF program (originally ADC/AFDC) for families. When Congress
implemented this “economies of scale” concept for married SSI recipients, they
did so with no consideration for the extra costs faced by people with
disabilities because of their disabilities.

And
since SSI monthly benefit amounts have not kept up with the steadily rising
costs of food, shelter and transportation, etc., an SSI dollar buys less and
less every year. “Priced Out in 2006,” a
national housing study published in 2007, found that the national average rent
for a studio/efficiency apartment was less than a full SSI monthly
benefit.

A
further complication exists for people with disabilities because the definition
of "married" under the SSI program is broader than the common definition. The Social Security Administration (SSA) may
deem a couple to be “married” for SSI purposes if they “hold themselves out
as20husband and wife to their community,” even though they do not meet the legal
definition for marriage in the state in which they live. The expanded definition of marriage applies
to situations where either one or both members of a couple are receiving
SSI.

Typically
when applying for SSI, proof of marital status is not required if the person
does not live with an unrelated person of the opposite sex, and claims not to be
married. However, if a person lives with
an unrelated person of the opposite sex, each must explain their relationship
and answer certain questions. Some of
these questions include what names the two are known by, whether they introduce
themselves as “husband and wife,” what names they use on their mail,
who owns or rents their home, and if there are any bills, installment contracts,
tax returns or other papers that show them as husband and wife.

How
people answer those questions, along with other factors, is used by SSA to
determine whether two individuals have “held themselves out to the community as
married." Therefore, SSA can consider a
couple to be married even if the couple has never been legally
married.

Too often, people with disabilities who rely
on SSI choose to live secretly with a partner to maintain vital benefits at
amounts that barely cover basic food and shelter costs.

The
U.S. Supreme Court has found that SSA’s marriage penalty does not violate the
Due Process Clause of the Fifth Amendment, which prevents the government from
depriving citizens of property, without due process. Unless another avenue for
legal challenge emerges, Congress is the remedy for any potential “fix” that
would change SSA regulations so that each beneficiary is treated as an
individual.

###

Disability
Rights Montana is the federally mandated civil rights Protection & Advocacy System for Montana. Our mission is to protect and advocate for the human, legal, and civil rights of Montanans with disabilities while advancing dignity, equality, and self-determination.

September 26, 2008

Including People in Institutions as "Homeless."Information Bulletin #262

This is a very brief FYI. Last week in the NY Times, it was reported that "lawmakers in Congress are debating who should be considered homeless."

This is a very important definition, because different Congressional and HUD programs are targeted to persons who are "homeless" and are denied to persons who do not meet the definition.

The NY Times stated that the House and Senate are considering an expansion of the definition "to include people precariously housed: those doubled up with friends or relatives or living day to day in motels, with money and options running out." Also being discussed is whether to include "families in desperate need of stable housing" or "people fleeing their homes because of domestic violence and those who can prove they will lose their housing within 14 days."

Missing, obviously, are all the elderly and people with disabilities who are institutionalized in nursing facilities, and especially the 22.6% (309,580 people) of those institutionalized who stated they want to leave the institution and live in the community.

Residing in a nursing facility is not by any stretch a "home." There are none of the indicia of a home. There is no privacy, no kitchen, no rental agreement, no dignity, no opportunity to contest living conditions, and those are just the beginning! HUD, in the prior federal administration, acknowledged and wrote people living in a nursing facility were "homeless."

CMS has correctly written that housing is a primary barrier for many people to leave nursing facilities. Why should one hand of the federal government, i.e., CMS, make payments (in FY 2006, $47.7 billion) for Medicaid recipients in nursing facilities, when another hand of the federal government, HUD, could significantly reduce those expenditures by defining people in institutions as "homeless" and therefore making them entitled to "homeless" housing funds so they could leave the nursing facilities.

Elderly and disability advocates:

We do not think your elected congressional or senatorial representatives have heard from you on this issue. If you want to increase the supply of affordable, accessible, integrated housing for people in nursing facilities, now is the time to do something. Telephone and write your federally elected officials and demand that people in institutions be included in the new definition for "homeless."

Republican vice-presidential nominee Sarah Palin has repeatedly pledged to be an advocate for parents of children with special needs. On the Democratic side, Sen. Joe Biden has voiced his concern for children with disabilities.

Yet neither campaign is addressing the issues - from health care to education to employment to access to technology - that are of vital concern to people with disabilities, like myself...

Photos from the White House signing ceremony for the ADA Amendments Act:

Photo 1 (President George W. Bush standing next to his father, Former President George H.W. Bush, who signed the original Americans with Disabilities Act into law in 1990)

Photo 2 (President George W. Bush signs the Americans with Disabilities Act Amendment Act in the Oval Office before an audience of Members of Congress, AAPD Board Chair Cheryl Sensenbrenner, and U.S. Attorney General Michael Mukasey)

September 25, 2008

Enabling the disabledA new law overturns years of callous Supreme Court decisions curtailing the rights of the disabled

The Americans with Disabilities Act of 1990, which then-President George H.W. Bush considered one of his administration's proudest accomplishments, was intended to give broad coverage to people with disabilities.

But in recent years the U.S. Supreme Court has consistently thwarted that intent with a series of decisions that narrowed the intended scope of the measure, denying constitutional protections to millions of disabled Americans.

Florida:LEE
COUNTY - The Department of Children and Families is investigating an
allegation that two school teachers laid on top of a five year-old
student with disabilities, sustaining injuries. >>MORE

Georgia:(Atlantic
Journal-Constitution, "Unclear results of privatizing mental health,"
9/21): Georgia is preparing to let for-profit companies take over much
of its troubled mental health system, even though little evidence
suggests privatization would save much money or improve care. >>MORE

New York:NEW
YORK - Parents of kindergarteners with disabilities are experiencing
difficulties finding appropriate placement for their children in light
of the cut-throat competition in admissions processes>>MORE (free registration may be required)

Frankie Mastrangelo is the moderator for both the Justice For All (JFA) national email listerv as well as for the JFActivist blog. She is also an organizer for the American Association of People with Disabilities in Washington, D.C.